Clinical outcomes for Saudi and Egyptian patients receiving deceased donor liver transplantation in China.

Long waiting list times in liver transplant programs in Saudi Arabia and unavailability of deceased donor transplantation in Egypt have led several patients to seek transplantation in China. All patients who received transplants in China and followed in three centers from January 2003-January 2007 were included. All patients' charts were reviewed. Mortality and morbidity were compared to those transplanted in King Faisal Specialist Hospital & Research Centre (KFSH&RC) during the same period. Seventy-four adult patients were included (46 Saudi nationals; 28 Egyptians). One-year and 3-year cumulative patient survival rates were 83% and 62%, respectively compared to 92% and 84% in KFSH&RC. One-year and 3-year cumulative graft survival rates were 81% and 59%, respectively compared to 90% and 84% in KFSH&RC. Compared to KFSH&RC, the incidence of complications was significantly higher especially biliary complications, sepsis, metastasis and acquired HBV infection posttransplant. Requirements of postoperative interventions and hospital admissions were also significantly greater. Our data show high mortality and morbidity rates in Saudi and Egyptian patients receiving transplants in China. This could be related to more liberal selection criteria, use of donation after cardiac death (DCD) donors or possibly more limited posttransplant care.

Nuclear imaging of the liver: is there a diagnostic role of HIDA in posttransplantation?

BACKGROUND AND AIMS: Biliary complications are common after liver transplantation. This study sought to assess the value of hepatic iminodiacetic acid (HIDA) scans (hepatobiliary iminodiacetic acid scan) to detect early posttransplantation biliary complications. METHODS: From April 2003 to June 2006, 34 liver transplantations (recipients of mean +/- SD age of 43.0 +/- 15.7 years) were performed in 25 (73.5%) males from 20 (58.8%) cadaveric donors and 14 (41.2%) living-related donors. The subjects underwent HIDA scans using a single head gamma camera Meridian (Philips) after intravenous (IV) administration of 185 MBq Tc-99m Disofenin. The mean time +/- SD posttransplantation to HIDA scan was 14.6 +/- 18.2 days (range, 0-74). The results were compared with endoscopic retrograde cholangio pancreatography, magnetic resonant cholangiopancreatography, percutaneous cholangiograhy, and/or liver biopsy. RESULTS: Twenty-four abnormalities were detected by HIDA scan in 16 patients (47.1%): 10 (29.4%) biliary leaks; 4 (11.4%) biliary obstruction or cholestasis; 1 (2.9%) delayed uptake; 5 (14.7%) delayed blood pool clearance; and 8 (23.5%) delayed transit to the bowel. The complications were more common among living-donor compared with deceased-donor graft recipients, albeit a not statistically significant difference (P = .066). Total and direct bilirubin levels were significantly higher in patients with abnormal than normal HIDA scans (P = .011 and P = .040, respectively). The sensitivity and specificity of HIDA scans to detect overall postoperative complications were 100% and 66.7%, respectively. Biliary leak results were false positives in 7/10 patients, and true in 3. Detection of obstruction was 75% sensitive by HIDA. CONCLUSION: HIDA scans are a noninvasive, reliable modality for early exclusion of posttransplantation biliary complications. However, correlation with clinical status and imaging modalities is essential to confirm detected abnormalities.

Donor outcome after living liver donation: a single-center experience.

OBJECTIVES: To objectively evaluate outcomes after living donor hepatectomy. PATIENTS AND METHOD: Between November 2002 and August 2006, a total of 44 procedures were performed (35 right, eight left, and one aborted after surgical incision). The Clavien classification was used to record surgical complications as follows: grade I, alterations from the ideal postoperative course not requiring specialized pharmacological or surgical treatment; grade II, complications requiring specialized pharmacological treatment, blood transfusion, or total parental nutrition; grade III-a, complications requiring invasive intervention without general anesthesia; Grade III-b, requires general anesthesia; Grade IV-a, single organ dysfunction; Grade IV-b, multiorgan dysfunction; grade V, death; The suffix "d" indicated disability. In this study, grades I and II complications were considered minor, while grades III and V and any lasting disability, serious complications. RESULTS: Male/female ratio was 34/10; median age was 25 years (range, 18 to 42); median hospital stay was 6 days (range, 4 to 14); and only two donors required intraoperative blood transfusion. After a median follow-up of 529 days (range, 8 to 1354), a total of 28 morbidities were encountered in 17 donors (38.6%), including nine donors (20.4%) who had serious complications. Among the 28 donor morbidities, 18 were grade I complications; three were grade III-a complications; five were grade III-b complications; and two were grade IV-a complications. No death was encountered in our experience. CONCLUSIONS: In our experience, donor hepatectomy was not an entirely safe procedure; therefore, extreme care should always be given by the transplant teams to living donors to avoid any distressing morbidity or even, the less likely but more catastrophic, mortality.

Liver transplantation for autoimmune hepatitis: a single-center experience.

OBJECTIVE: To present our experience with deceased donor liver transplantation (DDLT) and living-donor liver transplantation (LDLT) for autoimmune hepatitis (AIH). PATIENTS AND METHOD: Between April 2001 and November 2006, a total of 116 LT procedures were performed (73 DDLTs and 43 LDLTs) in 112 patients (4 retransplants). Of the 112 recipients, 16 patients (14.3%) were transplanted for AIH (15 DDLTs and 1 LDLT). All recipients received FK506- and steroid-based immunosuppressive regimens. RESULTS: The male/female ratio was 3/13, median age was 22 years (range, 15 to 35), and the median MELD score was 25 (range, 11 to 40). Arterial reconstruction was needed in four DDLTs due to severe steroid-induced angiopathy. After a median follow-up period of 530 days (range, 11 to 2016), the overall patient and graft survival rates were 93.8%. Only one patient died following LDLT due to primary graft nonfunction. Histopathologic recurrence was seen in three patients (18.7%) and was successfully treated by optimizing immunosuppression. Markedly elevated serum CA19-9 levels (median, 1069; range, 217 to 2855) was seen in four patients (28%), malignancy was ruled out and all patients normalized serum CA19-9 levels within the first 3 months posttransplant. Steroids withdrawal failed in all recipients and was always accompanied with almost immediate elevation of liver enzymes. CONCLUSIONS: In our experience, LT for AIH shows excellent long-term outcomes, patients are usually young women who present with acute deterioration and high MELD scores, and usually require long-term steroids to prevent rejection and disease recurrence. Some patients have markedly high CA19-9 in absence of malignancy. Some patients also have severe steroid-induced hepatic artery angiopathy necessitating arterial reconstruction during the transplant surgery.

The challenge of finding donors for living donor liver transplantation in Saudi Arabia.

INTRODUCTION: Organ shortage remains the main limiting factor for expanding liver transplantation (LT) in Saudi Arabia. Therefore, living donor liver transplantation (LDLT) was recently undertaken by our team at King Faisal Specialist Hospital and Research Center (KFSH&RC), in an effort to meet the increasing demand for LT in Saudi Arabia. OBJECTIVE: Analysis of donors assessed for LDLT at KFSH&RC. METHODS: Between September 2002 and May 2003, 39 potential donors were assessed for LDLT. First- or second-degree relationship to the recipient was an essential precondition. Assessment included biochemical testing, radiological studies (computed tomography: magnetic resonance angiography, magnetic resonance cholangiography), and thorough psychosocial analysis. Liver biopsy and hepatic angiogram was performed in some but not all donors. RESULTS: Male:female ratio was 28:11. Median age was 27 (18 to 34). Of 39 potential donors, only three underwent LDLT. The remaining 36 were rejected for different reasons including: psychosocial in 8 (20.5%), fatty liver in 7 (17.9%), recipient issues in 6 (15.4%), refusal after initial approval in 3 (7.7%), unfavorable anatomy in 2 (5.1%), inadequate liver volume in 2 (5.1%), abnormal liver functions in 2 (5.1%), hepatitis C virus in 2 (5.1%), liver pathology in 1 (2.6%), and other medical concerns in remaining 3 donors (7.7%). CONCLUSION: In Saudi Arabia, donor availability as well as recipient characteristics may limit the value of LDLT in overcoming organ shortage. Therefore, efforts should be directed to improve the number and quality of available cadaveric organs. Until then, LDLT may be the only way forward to save patients from dying on the waiting list.